Attention: See IRS Publications 1141, 1167, 1179 and other IRS resources for information about printing these tax forms.

Transcription

1 Attention: This form is provided for informational purposes only. Copy A appears in red, similar to the official IRS form. Do not file copy A downloaded from this website. The official printed version of this IRS form is scannable, but the online version of it, printed from this website, is not. A penalty of $50 per information return may be imposed for filing forms that cannot be scanned. To order official IRS forms, call TAX-FORM ( ) or Order Information Returns and Employer Returns Online, and we ll mail you the scannable forms and other products. See IRS Publications 1141, 1167, 1179 and other IRS resources for information about printing these tax forms.

2 7373 VOID CORRECTED CORPORATION S name, street address, city, state, ZIP code, and telephone no. CORPORATION S federal identification no. SHAREHOLDER S name Street address (including apt. no.) City, state, and ZIP code Account number (see instructions) SHAREHOLDER S identification no. 1 2 $ 3 5 Date of sale or exchange Aggregate amount rec d* No. of shares exchanged OMB No Classes of stock exchanged * The shareholder cannot claim a loss based on the amount in box 2. Changes in Corporate Control and Capital Structure Copy A For Internal Revenue Service Center File with Form For Paperwork Reduction Act Notice, see the 2009 General Instructions for Forms 1099, 1098, 3921, 3922, 5498, and W-2G. Cat. No M Department of the Treasury - Internal Revenue Service Do Not Cut or Separate Forms on This Page Do Not Cut or Separate Forms on This Page

3 CORPORATION S name, street address, city, state, ZIP code, and telephone no. CORPORATION S federal identification no. SHAREHOLDER S name Street address (including apt. no.) City, state, and ZIP code Account number (see instructions) SHAREHOLDER S identification no. CORRECTED (if checked) 1 2 $ 3 5 Date of sale or exchange Aggregate amount rec d* No. of shares exchanged OMB No Classes of stock exchanged * You cannot claim a loss based on the amount in box 2. Changes in Corporate Control and Capital Structure Copy B For Shareholder This is important tax information and is being furnished to the Internal Revenue Service. If you are required to file a return, a negligence penalty or other sanction may be imposed on you if taxable income results from this transaction and the IRS determines that it has not been reported. (keep for your records) Department of the Treasury - Internal Revenue Service

4 Instructions for Shareholder A corporation in which you own stock that has had a change in control or a substantial change in capital structure must send you this statement by January 31 of the year following the calendar year of the change. You have received this statement because the corporation has reasonably determined that you may be required to recognize gain from the receipt of cash, stock, or other property that was exchanged for the corporation s stock. Report any gain from the exchange on Schedule D (Form 1040), Capital Gains and Losses. However, you cannot claim a (loss) on Schedule D (Form 1040) as a result of this exchange. See Pub. 550, Investment Income and Expenses, chapter 4, for additional information. Account number. May show an account or other unique number the payer corporation assigned to distinguish your account. Box 1. Shows the date the stock was exchanged for cash, stock, or other property. Box 2. Shows the aggregate amount of any cash and the fair market value of any stock or other property received by you in the exchange for the stock you held. Box 3. Shows the number of shares of the corporation s stock that you held which were exchanged in the transaction. Box 4. Shows the class or classes of stock that were exchanged.

5 VOID CORRECTED CORPORATION S name, street address, city, state, ZIP code, and telephone no. 1 Date of sale or exchange 3 No. of shares exchanged CORPORATION S federal identification no. SHAREHOLDER S identification no. SHAREHOLDER S name Street address (including apt. no.) 5 City, state, and ZIP code 2 $ Aggregate amount rec d* OMB No Classes of stock exchanged Changes in Corporate Control and Capital Structure Copy C For Corporation For Paperwork Reduction Act Notice, see the 2009 General Instructions for Forms 1099, 1098, 3921, 3922, 5498, and W-2G. Account number (see instructions) * The shareholder cannot claim a loss based on the amount in box 2. Department of the Treasury - Internal Revenue Service

6 Instructions for Corporations General and specific form instructions are provided as separate products. The products you should use for 2009 are the General Instructions for Forms 1099, 1098, 3921, 3922, 5498, and W-2G and the 2009 Instructions for. A chart in the general instructions gives a quick guide to which form must be filed to report a particular payment. To order these instructions and additional forms, visit the IRS website at or call TAX-FORM ( ). Caution: Because paper forms are scanned during processing, you cannot file with the IRS Forms 1096, 1098, 1099, 3921, 3922, or 5498 that you print from the IRS website. Due dates. Generally, furnish Copy B of this form to the shareholder by February 1, However, if the recipient is a clearing organization, furnish Copy B by January 5, File Copy A of this form with the IRS by March 1, If you file electronically, the due date is March 31, To file electronically, you must have software that generates a file according to the specifications in Pub. 1220, Specifications for Filing Forms 1098, 1099, 3921, 3922, 5498, and W-2G Electronically. IRS does not provide a fill-in form option. Need help? If you have questions about reporting on, call the information reporting customer service site toll free at or (not toll free). For TTY/TDD equipment, call (not toll free).